Long COVID quality of life and healthcare experiences in the UK: a mixed method online survey.

PURPOSE: The complexity of long COVID and its diverse symptom profile contributes to unprecedented challenges for patients, clinicians, and healthcare services. The threat of long COVID remains ignored by Governments, the media and public health messaging, and patients' experiences must be heard through understanding of the lived experience. This study aimed to understand the lived experience of those living with long COVID. METHODS: An online web-based survey was designed using Patient and Public Involvement and Engagement (PPIE) to increase understanding of the lived experiences of long COVID, and was distributed through PPIE groups, social media, and word of mouth. The survey used closed and open questions relating to demographics, pre- and post-COVID-19 health quality of life, daily activities and long COVID experiences. RESULTS: Within our sample of 132 people living with long COVID, the findings highlight that individuals are being severely impacted by their symptoms and are unable to or limited in participating in their daily activities, reducing quality of life. Long COVID places strain on relationships, the ability to live life fully and is detrimental to mental health. Varying health care experiences are described by participants, with reports of medical gaslighting and inadequate support received. CONCLUSIONS: Long COVID has a severe impact on the ability to live life fully, and strains mental health. The appropriate mechanisms and support services are needed to support those living with long COVID and manage symptoms.

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study.

BACKGROUND AND AIM: Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid. METHODS: An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration. FINDINGS: Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources. CONCLUSION: We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma. PATIENT OR PUBLIC CONTRIBUTION: This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

Exploring the predictors of physical inactivity in a university setting.

BACKGROUND: Changes in lifestyle patterns and the dependence on technology have contributed to an increase in prevalence of inactivity. To address this there is a need to identify the predictors of physical inactivity using the Theoretical Domains Framework (TDF). METHODS: One hundred and twenty-one university administrative staff and 114 PhD students completed a survey. Physical activity (PA) levels were assessed using the Global Physical Activity Questionnaire (GPAQ), with participants scoring below 600 MET-minutes/week of total PA regarded as inactive. The predictors of physical inactivity were assessed using the Determinants of Physical Activity Questionnaire (DPAQ). Multiple regression analyses were used to identify which domains of the TDF predicted physical inactivity in the study samples. RESULTS: The results indicated that 64% of administrative staff (Mean = 411.3 ± 118.3 MET-minutes/week of total PA) and 62% of PhD students (Mean = 405.8 ± 111.0 MET-minutes/week of total PA) did not achieve the recommended PA levels. The physical skills domain (t 106 = 2.198, p = 0.030) was the significant predictor of physical inactivity amongst the administrative staff. Knowledge (t 99 = 2.018, p = .046) and intentions (t 99 = 4.240), p = 0.001) domains were the significant predictors of physical inactivity amongst PhD students. CONCLUSIONS: The results of this study should be used as a theoretical starting point in carrying out behavioural diagnosis, which could inform the design of effective interventions to increase PA levels in universities and other settings.

Application of theoretical domains framework to explore the enablers and barriers to physical activity among university staff and students: a qualitative study.

BACKGROUND: Physical inactivity is one of the major risk factors for developing several chronic illnesses. However, despite strong evidence indicating the health benefits of physical activity, many university staff and students tend to be physically inactive. University settings provide a stable environment where behaviour change interventions can be implemented across multiple levels of change. The aim of this study is to examine the perceived barriers and enablers to physical activity among staff and students in a university setting, using the Theoretical Domains Framework (TDF), a precursor of COM-B behaviour model. METHODS: This was a qualitative study carried out at a Midlands University in the United Kingdom. Eight group interviews were conducted with the sample (n = 40) consisting of 6 male and 15 female university staff (mean age = 40.5 ± 10.6 years) with different job roles (e.g., academic, administrative, cleaning and catering staff), and 12 male and 7 female students (mean age = 28.6 ± 4.7 years) at different stages of study (e.g., undergraduate, postgraduate, and international students). Interviews were audio recorded, transcribed verbatim and imported into NVivo12 software, responses were mapped using the TDF where theory-driven deductive content analysis was used for data analysis. RESULTS: Six prominent domains were identified from the group interviews as enablers and/or barriers to physical activity among university staff and students: Environmental context and resources; intentions; social influences; knowledge; beliefs about capabilities; and social/professional role and identity. The themes emerging from the group interviews fit into all 14 domains of the TDF; however, 71% of the themes fit into the six most prominent domains. CONCLUSIONS: These findings suggest that several enablers and barriers influence university staff and students' capability, opportunity, and motivation to engage in physical activity. This study, therefore, provides a theoretical foundation to inform the development of bespoke interventions to increase physical activity among inactive university staff and students.

COVID-19 and the long-term cardio-respiratory and metabolic health complications.

Severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) transmission continues to impact people globally. Whilst the acute symptoms and management strategies are well documented, millions of people globally are experiencing a prolonged and debilitating symptom profile that is reported to last months and even years. COVID-19 is a multi-system disease however the magnitude of the effects and its associated legacy is presently not well understood. Early reports indicate that multidisciplinary approaches between clinical and non-clinical entities are needed to provide effective and rehabilitative patient support pathways and restore pre-COVID-19 quality of life and functional status. Accordingly, this review provides a summary of the impact on cardiovascular, inflammatory, respiratory, and musculoskeletal function following an acute COVID-19 infection along with the prolonged effects of long-COVID.

Causal systems mapping to promote healthy living for pandemic preparedness: a call to action for global public health.

COVID-19 has severely impacted population health and well-being globally. Acknowledging that COVID-19 will not be the world's last pandemic, improving healthy living factors (i.e., physical activity, healthful nutrition, healthy weight), which are important in mitigating negative outcomes of future infectious disease pandemics, should be prioritized. Although well-documented, promoting healthy living factors remains challenged by a lack of scalability and sustainability due, in part, to a mismatch between intervention focus on individual behavior change as opposed to recognizing complex and multifactorial causes that prevent people from living healthy lifestyles and maintaining them long-term (such as political will, economic benefits, urban planning, etc.). To recognize this complexity in promoting healthy living, we propose the application of systems science methods for the creation of a comprehensive causal systems map of healthy living factors in the context of COVID-19 to inform future pandemic preparedness. Generating such a map would benefit researchers, practitioners, and policy makers in multi-sector collaborative efforts to improve public health preparedness in the context of future pandemics in a scalable, sustainable, and equitable manner. This effort should be facilitated by a trusted and widely respected governing body with global reach.

COVID-19 infection and cardiometabolic complications: short- and long-term treatment and management considerations.

No abstract present.

A flow resistive inspiratory muscle training mask worn during high-intensity interval training does not improve 5 km running time-trial performance.

PURPOSE: There is little evidence of the ergogenic effect of flow-resistive masks worn during exercise. We compared a flow-resistive face mask (MASK) worn during high-intensity interval training (HIIT) against pressure threshold loading inspiratory muscle training (IMT). METHODS: 23 participants (13 males) completed a 5 km time trial and six weeks of HIIT (3 sessions weekly). HIIT (n = 8) consisted of repeated work (2 min) at the speed equivalent to 95% [Formula: see text]O2 peak with equal rest. Repetitions were incremental (six in weeks 1, 2 and 6, eight in weeks 3 and 4 and ten in week 5). Participants were allocated to one of three training groups. MASK (n = 8) wore a flow-resistive mask during all sessions. The IMT group (n = 8) completed 2 × 30 breaths daily at 50% maximum inspiratory pressure (PImax). A control group (CON, n = 7) completed HIIT only. Following HIIT, participants completed two 5 km time trials, the first matched identically to pre-intervention trial (ISO time), and a self-paced effort. RESULTS: Time trial performance was improved in all groups (MASK 3.1 ± 1.7%, IMT, 5.7 ± 1.5% and CON 2.6 ± 1.0%, p < 0.05). IMT improved greater than MASK and CON (p = 0.004). Post intervention, PImax and diaphragm thickness were improved in IMT only (32% and 9.5%, respectively, p = 0.003 and 0.024). CONCLUSION: A flow-resistive mask worn during HIIT provides no benefit to 5 km performance when compared to HIIT only. Supplementing HIIT with IMT improves respiratory muscle strength, morphology and performance greater than HIIT alone.

A critical review of citrulline malate supplementation and exercise performance.

As a nitric oxide (NO) enhancer, citrulline malate (CM) has recently been touted as a potential ergogenic aid to both resistance and high-intensity exercise performance, as well as the recovery of muscular performance. The mechanism has been associated with enhanced blood flow to active musculature, however, it might be more far-reaching as either ammonia homeostasis could be improved, or ATP production could be increased via greater availability of malate. Moreover, CM might improve muscle recovery via increased nutrient delivery and/or removal of waste products. To date, a single acute 8 g dose of CM on either resistance exercise performance or cycling has been the most common approach, which has produced equivocal results. This makes the effectiveness of CM to improve exercise performance difficult to determine. Reasons for the disparity in conclusions seem to be due to methodological discrepancies such as the testing protocols and the associated test-retest reliability, dosing strategy (i.e., amount and timing), and the recent discovery of quality control issues with some manufacturers stated (i.e., citrulline:malate ratios). Further exploration of the optimal dose is therefore required including quantification of the bioavailability of NO, citrulline, and malate following ingestion of a range of CM doses. Similarly, further well-controlled studies using highly repeatable exercise protocols with a large aerobic component are required to assess the mechanisms associated with this supplement appropriately. Until such studies are completed, the efficacy of CM supplementation to improve exercise performance remains ambiguous.

Cross-validation of Actigraph derived accelerometer cut-points for assessment of sedentary behaviour and physical activity in children aged 8-11 years.

AIM: To cross-validate previously calibrated Actigraph cut-points in children. METHODS: Twenty-eight children (50% boys) aged between 8 and 11 years of age (9.4 ± 1.4 years) performed a series of 5 minute bouts of activity reflective of different levels of PA from sedentary behaviour (SB) to moderate to vigorous physical activity (MVPA); V˙ O2 was assessed using breath-by-breath indirect calorimetry, and activity was assessed using Actigraph accelerometers worn on the hip and non-dominant wrist. The V˙ O2 values were then converted into age-specific METs (measured METs) and coded as SB, light PA and MVPA. Accelerometer data were analysed using previously calibrated cut-points at different epochs, that is 5, 15, 30 and 60 seconds. RESULTS: Receiver operating characteristic (ROC) curve analysis indicated that there was excellent discrimination of SB using the Evenson et al (15 seconds), Romanzini (15 seconds), Treuth et al (30 seconds), Freedson et al (60 seconds), Treuth et al (60 seconds) and Troiano et al (60 seconds) cut-points. ROC analysis indicated poor discrimination for LPA irrespective of the cut-points used. Good discrimination of MVPA was evident for all existing cut-points using a 60-second epoch. CONCLUSION: There is considerable variation in the performance of existing cut-points for assessment of SB, LPA and MPA in children.

Calibration and Cross-Validation of Accelerometery for Estimating Movement Skills in Children Aged 8-12 Years.

(1) Background: This study sought to calibrate triaxial accelerometery, worn on both wrists, waist and both ankles, during children's physical activity (PA), with particular attention to object control motor skills performed at a fast and slow cadence, and to cross-validate the accelerometer cut-points derived from the calibration using an independent dataset. (2) Methods: Twenty boys (10.1 ±1.5 years) undertook seven, five-minute bouts of activity lying supine, standing, running (4.5kmph-1) instep passing a football (fast and slow cadence), dribbling a football (fast and slow cadence), whilst wearing five GENEActiv accelerometers on their non-dominant and dominant wrists and ankles and waist. VO2 was assessed concurrently using indirect calorimetry. ROC curve analysis was used to generate cut-points representing sedentary, light and moderate PA. The cut-points were then cross-validated using independent data from 30 children (9.4 ± 1.4 years), who had undertaken similar activities whilst wearing accelerometers and being assessed for VO2. (3) Results: GENEActiv monitors were able to discriminate sedentary activity to an excellent level irrespective of wear location. For moderate PA, discrimination of activity was considered good for monitors placed on the dominant wrist, waist, non-dominant and dominant ankles but fair for the non-dominant wrist. Applying the cut-points to the cross-validation sample indicated that cut-points validated in the calibration were able to successfully discriminate sedentary behaviour and moderate PA to an excellent standard and light PA to a fair standard. (4) Conclusions: Cut-points derived from this calibration demonstrate an excellent ability to discriminate children's sedentary behaviour and moderate intensity PA comprising motor skill activity.

Impact of Weekly Swimming Training Distance on the Ergogenicity of Inspiratory Muscle Training in Well-Trained Youth Swimmers.

Lomax, M, Kapus, J, Brown, PI, and Faghy, M. Impact of weekly swimming training distance on the ergogenicity of inspiratory muscle training in well-trained youth swimmers. J Strength Cond Res 33(8): 2185-2193, 2019-The aim of this study was to examine the impact of weekly swimming training distance on the ergogenicity of inspiratory muscle training (IMT). Thirty-three youth swimmers were recruited and separated into a LOW and HIGH group based on weekly training distance (≤31 km·wk and >41 km·wk, respectively). The LOW and HIGH groups were further subdivided into control and IMT groups for a 6-week IMT intervention giving a total of 4 groups: LOWcon, LOWIMT, HIGHcon, and HIGHIMT. Before and after the intervention period, swimmers completed maximal effort 100- and 200-m front crawl swims, with maximal inspiratory and expiratory mouth pressures (PImax and PEmax, respectively) assessed before and after each swim. Inspiratory muscle training increased PImax (but not PEmax) by 36% in LOWIMT and HIGHIMT groups (p ≤ 0.05), but 100- and 200-m swims were faster only in the LOWIMT group (3 and 7% respectively, p ≤ 0.05). Performance benefits only occurred in those training up to 31 km·wk and indicate that the ergogenicity of IMT is affected by weekly training distance. Consequently, training distances are important considerations, among others, when deciding whether or not to supplement swimming training with IMT.

Functional training of the inspiratory muscles improves load carriage performance.

Inspiratory Muscle Training (IMT) whilst adopting body positions that mimic exercise (functional IMT; IMTF) improves running performance above traditional IMT methods in unloaded exercise. We investigated the effect of IMTF during load carriage tasks. Seventeen males completed 60 min walking at 6.5 km·h-1 followed by a 2.4 km load carriage time-trial (LCTT) whilst wearing a 25 kg backpack. Trials were completed at baseline; post 4 weeks IMT (consisting of 30 breaths twice daily at 50% of maximum inspiratory pressure) and again following either 4 weeks IMTF (comprising four inspiratory loaded core exercises) or maintenance IMT (IMTCON). Baseline LCTT was 15.93 ± 2.30 min and was reduced to 14.73 ± 2.40 min (mean reduction 1.19 ± 0.83 min, p < 0.01) after IMT. Following phase two, LCTT increased in IMTF only (13.59 ± 2.33 min, p < 0.05) and was unchanged in post-IMTCON. Performance was increased following IMTF, providing an additional ergogenic effect beyond IMT alone. Practitioner Summary: We confirmed the ergogenic benefit of Inspiratory Muscle Training (IMT) upon load carriage performance. Furthermore, we demonstrate that functional IMT methods provide a greater performance benefit during exercise with thoracic loads. Abbreviations: [Lac-]B: blood lactate; FEV1: forced expiratory volume in one second; FEV1/FVC: forced expiratory volume in one second/forced vital capacity ratio; FVC: forced vital capacity; HR: heart rate; IMT: inspiratory muscle training; IMTCON: inspiratory muscle training maintenance; IMTF: functional inspiratory muscle training; LC: load carriage; LCTT: load carriage time trial; Pdi: transdiaphragmatic pressure; PEF: peak expiratory flow; PEmax: maximum expiratory mouth pressure; PImax: maximum inspiratory mouth pressure; RPE: rating of perceived exertion; RPEbreating: rating of perceived exertion for the breathing; RPEleg: rating of perceived exertion for the legs; SEPT: sport-specific endurance plank test; V̇ O2: oxygen consumption; V̇ O2peak: peak oxygen consumption.

Thoracic load carriage-induced respiratory muscle fatigue.

PURPOSE: We investigated the effect of carrying a 25 kg backpack upon exercise-induced respiratory muscle fatigue, pulmonary function and physiological and perceptual responses to exercise. METHODS: Nineteen healthy males performed 60 min walking at 6.5 km h(-1) and 0 % gradient with a 25 kg backpack (load carriage; LC). Following 15 min recovery participants then completed a 2.4 km time trial with the load (LCTT) and on a different day, repeated the trials without the load [control trial (CON) and control time trial (CONTT), respectively]. Respiratory muscle fatigue was determined by the transient change in maximal inspiratory (P Imax) and expiratory (P Emax) pressure prior to and immediately following exercise. RESULTS: P Imax and P Emax were reduced from baseline by 11 and 13 % (P < 0.05), respectively, post-LC but remained unchanged post-CON. Following the time trial P Imax and P Emax were reduced 16 and 19 %, respectively, post-LCTT (P < 0.05) and by 6 and 10 %, respectively (P < 0.05), post-CONTT compared to baseline. Both forced vital capacity and forced expiratory volume in 1 s were reduced by 4 ± 13 and 1 ± 9 %, respectively, during LC when compared to CON. Relative to CON all physiological and perceptual responses were greater in LC, both post-LC and -LCTT (P < 0.01). Time trial performance was faster during CONTT (11.08 ± 1.62 min) relative to LCTT (15.93 ± 1.91 min; P < 0.05). CONCLUSION: This study provides novel evidence that constant speed walking and time trial exercise with 25 kg thoracic load carriage induces significant inspiratory and expiratory muscle fatigue and may have important performance implications in some recreational and occupational settings.

Preloaded time trial to assess load carriage performance.

The relevance and importance of load carriage in recreational and occupational tasks has stimulated a large body of research. Exercise protocols have been criticized for a lack of relevance to occupational activities; accordingly, the aim of this study was to assess the reliability of a preloaded time-trial protocol for load carriage assessment. After full familiarization, 8 healthy males performed 2 trials separated by 1 week. Each trial comprised 60-minute walking at 6.5 km·h and 0% gradient (LC), 15 minutes seated recovery followed by a 2.4-km time-trial (LCTT). All trials were performed wearing a 25-kg backpack. Performance time was 16.71 ± 1.82 minutes and 16.37 ± 1.78 minutes for LCTT 1 and 2, respectively with a mean difference of -0.34 ± 0.89 minutes. Using log ratio limits of agreement, the mean bias was 1.02 and random error component of the agreement ratio was 1.11. The intraclass correlation was 0.85, coefficient of variation was 10.5%, and Cohen's d was 0.35. The protocol demonstrated a very good level of reliability. We present a novel and reliable preloaded time-trial protocol that more closely reflects operational activities and can be used to quantify load carriage performance. This protocol provides greater ecologically validity regarding physical demands of load carriage activities than those adopted previously and provides an excellent tool for the strength and conditioning practitioner to assess individual load carriage performance.

How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis.

Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.

Using cardiorespiratory fitness assessment to identify pathophysiology in long COVID - Best practice approaches.

Cardio-respiratory fitness (CRF) is well-established in the clinical domains as an integrative measure of the body's physiological capability and capacity to transport and utilise oxygen during controlled bouts of physical exertion. Long COVID is associated with >200 different symptoms and is estimated to affect ∼150 million people worldwide. The most widely reported impact is reduced quality of life and functional status due to highly sensitive and cyclical symptoms that manifest and are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli, more commonly known as post-exertional symptom exacerbation (PESE) which prevents millions from engaging in routine daily activities. The use of cardiopulmonary exercise testing (CPET) is commonplace in the assessment of integrated physiology; CPET will undoubtedly play an integral role in furthering the pathophysiology and mechanistic knowledge that will inform bespoke Long COVID treatment and management strategies. An inherent risk of previous attempts to utilise CPET protocols in patients with chronic disease is that these are compounded by PESE and have induced a worsening of symptoms for patients that can last for days or weeks. To do this effectively and to meet the global need, the complex multi-system pathophysiology of Long COVID must be considered to ensure the design and implementation of research that is both safe for participants and capable of advancing mechanistic understanding.

Developing effective strategies to optimize physical activity and cardiorespiratory fitness in the long Covid population- The need for caution and objective assessment.

The Post Covid-19 Condition (commonly known as Long Covid) has been defined by the World Health Organisation as occurring in individuals with a history of probable or confirmed SARS CoV 2 infection, usually within 3 months from the onset of acute Covid-19 infection with symptoms that last for at least two months which cannot be explained by an alternative diagnosis. Long Covid is associated with over two hundred recognised symptoms and affects tens of millions of people worldwide. Widely reported reductions in quality of life(QoL) and functional status are caused by extremely sensitive and cyclical symptom profiles that are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli. This manifestation prevents millions of people from engaging in routine activities of daily living (ADLs) and has important health and well-being, social and economic impacts. Post-exertional symptom exacerbation (PESE) (also known as post-exertional malaise) is an exacerbation in the severity of fatigue and other symptoms following physical, emotional, orthostatic and cognitive tasks. Typically, this will occur 24-72 h after "over-exertion" and can persist for several days and even weeks. It is a hallmark symptom of Long Covid with a reported prevalence of 86%. The debilitating nature of PESE prevents patients from engaging in physical activity which impacts functional status and QoL. In this review, the authors present an update to the literature relating to PESE in Long Covid and make the case for evidence-based guidelines that support the design and implementation of safe rehabilitation approaches for people with Long Covid. This review also considers the role of objective monitoring to quantify a patient's response to external stimuli which can be used to support the safe management of Long Covid and inform decisions relating to engagement with any stimuli that could prompt an exacerbation of symptoms.

The physiologic benefits of optimizing cardiorespiratory fitness and physical activity - From the cell to systems level in a post-pandemic world.

Cardiovascular (CV) disease (CVD) is a leading cause of premature death and hospitalization which places a significant strain on health services and economies around the World. Evidence from decades of empirical and observational research demonstrates clear associations between physical activity (PA) and cardiorespiratory fitness (CRF) which can offset the risk of mortality and increase life expectancy and the quality of life in patients. Whilst well documented, the narrative of increased CRF remained pertinent during the coronavirus disease 2019 (COVID-19) pandemic, where individuals with lower levels of CRF had more than double the risk of dying from COVID-19 compared to those with a moderate or high CRF. The need to better understand the mechanisms associated with COVID-19 and those that continue to be affected with persistent symptoms following infection (Long COVID), and CV health is key if we are to be able to effectively target the use of CRF and PA to improve the lives of those suffering its afflictions. Whilst there is a long way to go to optimise PA and CRF for improved health at a population level, particularly in a post-pandemic world, increasing the understanding using a cellular-to-systems approach, we hope to provide further insight into the benefits of engaging in PA.